Have you had a fever in the last 24 hours of 100°F or above? *

Yes

No

Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath? *

Yes

No

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms? *

Yes

No

I further acknowledge that I am voluntarily participating in the above referenced activities with the full knowledge and understanding that said activities are taking place during the COVID-19 pandemic. I understand that while Synergy Wellness Center LLC and its employees and contractors will abide by all local, state, and federal government laws and guidelines, as well as CDC guidelines, in an attempt to keep employees and patients safe, that I assume ALL risks associated with participation in said activities during said pandemic, including but not limited to: any illness and any adverse physical and/or psychological effects from the same and/or loss of any income or other monetary loss incurred as a result of the effects of said illness and/or costs incurred in the treatment of the same. I accept full and total responsibility for my own health and agree to release, hold harmless, and indemnify, to the extent permitted by the law, Synergy Bioenergetic Wellness, its employees and contractors from any liability for any illness, injury, loss or damages I many incur as a result of contracting COVID-19 as a result of engaging in said above referenced activities. I have read, understand, and agree to the content of this Agreement and voluntarily agree to the terms and conditions stated above. If the terms of this Agreement are acceptable, please sign the acceptance below. By doing so, the Client acknowledges that he/she understands, accepts and agrees to abide by the terms hereof (Must be over age 18). *

First Name

Last Name

Date *

MM

DD

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